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Mitral Stenosis

In mitral stenosis the mitral valve is diseased and does not open all of the way; the valve is too "tight".  The primary cause of mitral stenosis has been rheumatic fever.  Rheumatic fever is a result of untreated strep infections and has become much less common in the United States; it is still a problem in many third-world countries.  Mitral stenosis is becoming more and more uncommon in this country.

Symptoms

• Shortness of breath: Because the problem is that the mitral valve is too "tight", there is difficulty in getting blood from the left atrium into the left ventricle.  Therefore, the ventricle does not have to struggle with getting blood out of the heart and it does not develop failure itself.  However, pressure builds up behind the mitral valve and this causes the lungs to fill up with fluid.
• Coughing up blood: If the pressure build-up in the blood vessels of the lungs is very severe, the patient may actually cough up blood.
• Atrial fibrillation: An irregular heart rhythm.  Because the atrium does not contract well with atrial fibrillation and because blood tends not to move well from the atrium to the ventricle with the narrowed mitral valve, blood tends to stagnate and form clots.  These may then break off and go to the brain (causing a stroke) or other vital organs.

Diagnosis

• Echocardiogram: This ultrasound examination of the heart can provide images of the diseased mitral valve and the area of opening can be estimated.  The normal mitral valve opening measures around 4-5 cm2.  Symptoms related to mitral stenosis usually occur when the valve area is less than 2.5 cm2.
• Transesophageal echocardiograms can provide even better pictures.
• Cardiac catheterization is useful to determine if there are blockages in the heart arteries, and the pressure in the blood vessels to the lungs can be measured.

Medical Treatment

There are no medicines that will treat an obstructed mitral valve, which is a mechanical problem.  Based on certain factors, blood thinners such as warfarin may be used to prevent blood clot problems.  Patients frequently develop atrial fibrillation, and there are medicines which can help control this irregular heart rhythm.

In certain circumstances, a balloon valvuloplasty may be performed in the patient with symptomatic mitral stenosis or even asymptomatic mitral stenosis if the pressure in the arteries to the lungs is too high (greater than 60 mmHg), or the patient develops atrial fibrillation.  In this procedure, performed by a cardiologist, a catheter with an inflatable balloon is passed across the valve and the balloon is inflated, thus opening up the valve.  This procedure can provide relief, but is generally not recommended if there is the presence of blood clot in the atrium, the valve is leaking as well as too "tight", or the appearance of the valve suggests valvuloplasty would not work.  Balloon valvuloplasty is usually done in experienced centers.

Surgical Treatment

• Indications: Surgery is indicated for patients with New York Heart Association Class III symptoms (severe limitation with exercise) or Class IV symptoms (symptoms at rest and discomfort with any activity) who are not candidates for balloon valvuloplasty.  The reasons for this are: 
  • The valve does not look like a valve that could be successfully opened by a valvuloplasty. 
  • There is a blood clot in the heart
  • The valve is leaking as well as too "tight"
• Early Surgery
  • Pulmonary hypertension: Patients with no symptoms or mild symptoms with exercise can be considered for surgery if the pressure in the arteries in the lungs is excessive (greater than 60 mmHg) if a valvuloplasty is not possible.
  • Recurrent emboli: Patients with no symptoms of heart failure but who have had repeated episodes where blood clots have broken loose may also be considered for surgery.

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